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SAN JOAQl111�"CEIVED <br /> Environmental Health Department <br /> COUNTY SEP `l LUit PUBLIC RECORDS RELEASE APPLICATION <br /> EAPV1� W-Wt1 CES <br /> EHD LOG NUMBER• <br /> APPLICANT: E 1' ' BUSINESSIAGENCY:AEI COY\LQLk,L-}O_V"t� <br /> ADDRESS: U -0 3rc=Q+ c IAN1, 7 OCt. CITY/STATEIZIP:_0Le, l�CA lIq &I <br /> PHONE(1):5jQjj)�3j X.Zi(�1' PHONE(2): FAX ORE-MAIL: iagcLurtaro(rDQ•i.l(0i1QI(ztnfS <br /> Please allow 10 business days from date of application submittal for the records to be available. d n <br /> Staff will conrrang r n appointment date and time to review the requested records. <br /> SIGNATURE OF APPLICANT SU _/C/ DATE Qq r2�'I1 <br /> 1. List up to ten addresses in ace belo Address ranges WILL NOT be accepted. Select the type s)of fl es froom m the <br /> list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to(209)464.0138,mail to the <br /> address indicated below,or email to info(&sicehd.com Applications received after 3:00 pm will be processed the next <br /> business day. <br /> 2. For assistance in identifying the nature and content of EHD records,please contact EHD at the number noted below. <br /> 3. The EHD will notify the applicant if any EHD files exist An appointment for review will be confirmed approximately ten(10) <br /> days after receipt of application. The files will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$152 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:0DPM(EXCLUDING HOLIDAYS)/ <br /> Electronic Information: ❑ List❑ Map—Description: <br /> Specific Date Range of Information Requested: From _ Q to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT ( ponly, 9 p <br /> FILES S ecific atldresses address ranges will not be accepted) EHD USE ONLY <br /> Undeigmund Tank(UST) Street# Street Name $.��/� City <br /> �Ieanup SR.(LOP) NDY+h �t io IL4 SI ❑Coxsuman <br /> Other Cleanup Site(Non-LOP) i jJ T�� <br /> �azardaus Waste <br /> red Permitted Facility Y <br /> veground Tank <br /> P (Monitoring I Removal) ( ` `^� 2'?'-3'Z rt f'1 Pws <br /> H rdous Materials -1 I (�I r•r'l Release Response r 1 - f ...,,,/// <br /> ❑Solid Waste Facility/Vehicle <br /> �yW'^*�Ouaury <br /> Ford Facility <br /> ❑Pool/Spa SITE Mmw,loH <br /> Ej Dairy 5 <br /> Land Use Application Sites <br /> Septic Pumper Truck/ fi ❑Houswe <br /> Yard I Chemical Toilets <br /> Wastewater Treatment Plant [ji5CUPA <br /> Housing Abatement r AST/HM IHW <br /> Motel/Hotel <br /> Chicken Ranch/Dog Kennel f3�EUPA <br /> Medical Waste Facilby a O'�UST <br /> Tattoo/body Piercing <br /> wa Tire ❑souo wasra <br /> 9 <br /> pmiclaint <br /> Other(Please Specify): [3 Accwe'rm <br /> 10 <br /> —BOXED AREA-EHD USE ONLY- <br /> 13 Records provided by Staff-PPR Complete. Staff Name: EHo48416 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />